Single- versus two-stage revision surgery in the case of fracture-related infection: a systematic review

Background: This systematic review aimed to evaluate the current evidence regarding the clinical outcome of single- and two-stage revision procedures for long-bone fracture-related infection (FRI). The review focused on unhealed fractures without critical-sized bone defects, treated with internal fixation. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. A systematic search was carried out in PubMed, Embase via Elsevier, and Web of Science Core collection. Results: Out of 21 126 articles initially identified, 35 studies, including 985 patients, were eligible for the final analysis. A total of 27 studies assessed single-stage revisions, 5 examined two-stage procedures, and 3 included both approaches. The mean bone-healing rate was 80 % for single-stage approaches and 77 % for two-stage approaches. The mean infection eradication rate for single-stage revisions was 87 %, whereas two-stage revisions demonstrated a mean infection eradication rate of 81 %. Only five studies included patients ( $n=$ 34) diagnosed with an FRI within 6 months after the primary fracture fixation. Conclusion: For patients with unhealed long-bone FRIs without critical-sized bone defects, the current literature is of poor quality, heterogeneous, and lacks strong evidence to recommend either a single-stage or two-stage approach with internal fixation. For both protocols, the rate of revision surgery remains high. Furthermore, high-quality studies focusing on two-stage procedures, especially for the treatment of FRIs occurring within 6 months after initial fracture fixation, are almost non-existent. The identification of positive cultures during single-stage procedures for presumed aseptic fracture non-unions might be linked to poorer clinical outcomes.